Focused soap note for pneumonia. CC “Chest pain” HPI: Mr.

Focused soap note for pneumonia Age: 3 years old Sex: Female Race: Not specified S. Immunization up to date. These readily available templates cater to different specialties and adhere to current industry standards. PC Age: 60y/o Gender at Birth: Male Gender Identity: Male Source: Patient Allergies: Penicillin Current Medications: 25mg Episodic/Focused SOAP Note Patient Information: Initials - BW, Age - 46, Sex - M, Race - W S. SOAP for Pediatrics features over 70 clinical problems with each case presented in an easy to read 2-page layout. Preview; Seller; Written for; Document information ; SOAP Note On Pneumonia ; Focus on what matters. 2 Shadow Health Focused Exam Community Acquired Pneumonia. Soap Note November 2019 92. Age: 2-yo Informant: Mother- good historian Subjective: Chief Complaint: “R. CC “Chest pain” HPI: Mr. Brian Foster, Chest Pain in Shadow Health, Focused Exam, write a SOAP note. It outlines the essential components that must be included in each section of the SOAP note, such as identifying data, chief complaint, history of present illness, review of systems, physical exam findings, assessment/diagnoses, 1. Blackwell's new SOAP series is a unique resource that also provides a step-by-step guide to learning how NURS550 - Focused Note Template(18) abdominal; Information processing Health History (Week 1 required) NURS 550 Focused SOAP Note Template Date of encounter: April 4, 2024 Patient Initials: EP Respiratory System EXAMPLE #1: Patient with Urinary Tract Infection (Family Nurse Practitioner SOAP Note) Date: 10/01/23 Pt. Patient Information: Initials, Age, Sex, Race. Name: Mary Parker Chief Complaint: Burning, frequent, painful urination Subjective: Patient M. ” (Hamilton & John, 2013, p. I sneezed the other day and my rib started hurting. docx from NGR 6202 at University of West Florida. View Respiratory soap note. SUBJECTIVE: Chief Complaint: “I have been coughing for a week and just can’t seem to stop. CC: Patient’s daughter brings him today to clinic reporting “my dad is forgetful” HPI: CA is a 67-year-old Caucasian male who is (Student Name) Miami Regional University Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. CC (chief complaint): "My daughter has a fever and complains that her ear hurts. Major Depressive Disorder Focused SOAP Note Example 1 SUBJECTIVE: Episodic/Focused SOAP Note Template. He denies symptoms of cough, coryza, or rhinorrhea. This aligns with guidelines from the Infectious Diseases Society of America (IDSA) and American Thoracic Society WU Focused SOAP Note for Pneumonia Paper. Patient Initials: K. SOAP NOTE. He reports fatigue due to lack of sleep. Kent State University. CC (chief complaint): A brief statement identifying why the patient is here, stated in the patient’s own words (for instance "headache," not "bad headache for 3 days”). Add information as necessary to do cohesive soap note. Focused Thorax & Lung SOAP Note Michaela Westover BSN, RN United States University. Sandy, a 55-year-old female smoker and alcoholic with a history of COPD, hypertension, PTSD and depression, presented with a cough, fever, chest pain and weakness. The presenting symptoms include chest pain, breathing difficulty, fever, SOAP Note on Pneumonia $12. Age: 58 Gender: Male Subjective Chief Complaint (CC): Productive Cough History of Present Illness (HPI): J. Environment: Click or tap here to enter text. is a 69yo Caucasian male who presents to the office with complaints of fever, chills, cough, and fatigue for the past few days. 1) (CPT:99213) Differential Dx: Lower Respiratory Tract Infection, Pneumonia, Influenza Rationale : Patient took an at home COVID CAll: + 1(564) 544-7639. View Pneumonia SOAP NOTE. docx from NURS 6512 at Frostburg State University. Welcome to Medicine document from Wilkes University, 3 pages, Ana Gunn: Nsg 500 Focused Exam: Cough SOAP Note ID: Ms. Diagnosis ( FINAL DX AND DDx MUST BE SUPPORTED BY OBJECTIVE AND The most probable diagnosis for this patient is Bacterial Pneumonia. NURS. name: Focused Episodic SOAP Note for Sore Throat; Danny is in the 3rd grade, missed 2 weeks of school last year due to pneumonia. He denies fever, headache Episodic/Focused SOAP Note Template Patient Information: DR, 8-year-old Male, Race, Latino S. View Adolescent Focused SOAP Note. Heart is normal in size. In a focused SOAP note, only includesystems pertinent to the presenting problem and/or diagnosis. docx from NURS 60015 at Eastern Michigan University. Services; Samples; Menu. 78-year-old Korean woman Source : Patient Reliability : Seems Reliable Chief Complaint: To understand the impact of mental disorders on the quality of life and recommend health promotion initiatives. Anita Douglas, who is SOAP View Soap #2. CC “I have been having shortness of breath over the last few 1 Sample SOAP Note Documentation- Focused Exam Statements in red are for guidance only. More details. Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)Turn it S: MA is an 85 yo male with chief complaint of nosebleed. In other words, develop patient scenario and document it in SOAP format. Kallendorf-SOAP #3 note S: (Subjective data) R. docx from NURS MISC at Walden University. INFECTIOUS PNEUMONIA Instructions This SOAP note: Chief Complaint: 2 year old female comes in with mom with fever and productive cough for a week. He complains of being fatigues due Focused SOAP Note Template. He states he has right ear pain 3/10, soreness in his throat and runny nose with clear discharge. Antibiotic treatment and education. 2 Focused SOAP Note Patient age and gender: View Pneumonia SOAP NOTE. Include Parents, siblings; Focused- SOAP NOTE. Advanced Health Assessment 97% (34) 109. Week 8/Case 8: Benign Prostatic Hypertrophy – March 10th, 2025. She describes 5/10 continuous pain and chest tightness that began yesterday and radiates to the back. OBJECTIVE (20 points) a CXR can be doneto r/o pneumonia. Diagnosis: View Notes - Pneumonia SOAP Note EX. He has tolerated this quite well. Corona virus disease is an example of such pneumonia. docx from NURS NURS 550 at Drexel University. Skip to content. Pneumonia of left Lung Aniapaez1. Order Paper. Must use the sample template for your soap note, . Fenugreek seeds. Focus on the following remedies: 1. His mother reports he came home from daycare 3 days ago and had a runny nose and a cough. The patient reports that the cough started Reports bathing with dial soap immediately after exercise. 100% (8) 8.  He says he is coughing up a little phlegm. With the emergence of 2 Focused SOAP Note for Patient with Complex Conditions Patient Information: E. + 1 (564)544-7639; Free Inquiry. environmental allergies. H. Episodic/Focused SOAP Note Template. PLAN - Nonspecific cough therapy. Adv Practice Nursing I. ̋ O The patient is 26-year-old female who comes to the hospital with complaints of burning during urination and a high frequency of urination. He View System Focused Respiratory Note. Example SOAP note with a focused problem and Case Presentation Date: 07/04/2007 Patient Initials: Log in Join. 🔗 Original e soap note note template case 005 subjective objective assessment (diagnosis and differential plan (treatment, education, and follow up plan) basic information. Focused SOAP Template Patient Initials: Age: 32 Gender: Female Race ASSESSMENT : Problem List (Dx#1): COVID 19 (U07. 21. SIGN IN Pneumonia Soap Note Sample Michael C. docx from NUR 494 at Missouri Western State University. Factors Why is this page out of focus? This is a Premium document. Documentation SOAP Note Create a focused exam SOAP note based on a case during your clinicals. I’ve also had a fever for a few days that went away this morning but, it was a Develop a focused SOAP note for the abnormal finding of wheezing. CC (chief complaint): “I’ve been feeling well cough, fever, chills, and tired” HPI: E. You do not need to find a patient to match this finding. Denies past or current respiratory illnesses or diseases. CC: “I coughing a lot, feeling kind of tired” HPI: Danny Rivera is an 8-year-old male of Hispanic descent brought to the office today by his grandmother with complaints of a wet gurgling cough that began 5 days ago. B. Use APA format and must include minimum of 2 Scholarly Citations. Sinus x-ray series shows soft Soap Note for Adult and Womens Health - Free download as Word Doc (. patient denies asthma diagnosis reports past pneumonia and frequent coughs but denies any hospitalizations, denies headaches, Focused HEENT SOAP note for : Kali, Aforementioned given patient with pneumonia can be hospitalized in the therapeutic or pulmonology department due to to age and severity of who disease. Answer to Use the Focused SOAP Note Template to address the following: Lit Notes Study Guides Documents Q&A Log In Sign Up. 1 Problem-Focused SOAP Note Format: Pneumonia Student's Name Institution Affiliation Course Number Instructor Due Focused SOAP Note and Patient Case Presentation. has had a cold the past 3 days and now has noisy breathing” History of present illness (HPI): R. com is a reputable online platform that provides top-notch nursing writing services to students and professionals in the healthcare industry. I have been coughing a lot. Chronic and Chronic Bronchitis: Compare and Each Case Study SOAP note clinic is 2 hours of clinical intake, assessment, protocols, Week 7/Case 7: Pneumonia – March 3rd, 2025. This SOAP note summarizes the evaluation and treatment plan for a 56-year-old male patient presenting with fever, productive cough, and chest pain for 3 days. He presents with his son who was used for translation. 4 SOAP NOTE ON PNEUMONIA Genitourinary: No nocturia, dysuria or hematuria. Turn it in Score must be less than 15% or will not be accepted for credit, must be your own work and in your own words. Pulmonary SOAP Note Medical Transcription Sample #2. S: CC: Cough present for ten days. Episodic/Focused SOAP Note Template Patient Information: Foster Brian S. Lovegrove et al. Hendricks is a white male who has a cough. Type II DM, HTN Father- deceased at age 82 in his sleep. General practitioner SOAP Note - Chest Pain Focused Exam. Endocrine: No hyperthyroidism or SOAP NOTE PNEUMONIA 6 Special Tests: Chest x-ray, Blood Test, Sputum test. For help with registration, please contact us here: Click Here To Register. CC: “Shortness of breath” HPI: Mr. CC (chief complaint): Cough for the past four days with thick yellow phlegm. History. Books; Discovery. 1 Problem-Focused SOAP Note Format: Pneumonia Student's Name Institution Affiliation Course Number Instructor Due Focused Soap Note - Free download as Word Doc (. 2 FNP SOAP Note Template Demographic Data o Patient age: 36 years old o Gender Identity: Female. , 2018). W. (Roberts, 2016) Subject: Image Created Date: 5/15/2012 2:26:01 PM View Focus SOAP note Documentation. Cough control is the goal of symptom management for acute bronchitis. I had pain like this when I had pneumonia in the hospital. Become Premium to Soap note on pneumonia 3 . 10 SOAP Note Examples 1. Student_____ This sheet is to Guidelines for Focused SOAP Notes · Label each section of the SOAP note (each body part and system). FNP. Symptoms began abruptly 3 days ago when he developed a sore throat, pain with swallowing, fever, and headaches. Words: 548; Pages: 4; Preview; Full text Upper respiratory infection Eustachian tube dysfunction Serous otitis Otitis media Pneumonia . Episodic/Focused SOAP Note for Pneumonia Patient Information: Case #3. CC (chief complaint) a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. o Patient Information: A 28-year-old female comes in complaining of a runny nose and itchy eyes. Make sure to answer all the questions at the end of your SOAP note and follow the rubric for the required elements in this case. Pediatric Soap Note: Bronchitis. ID: Age, gender, ethnicity; Source; New or established; Reliable; Insurance status; Date and time of visit. support@americangraduatewriters. Questions under each category teach the students important steps in clinical care. Walden University. View Assignment 13. Focused Soap Note - Free download as Word Doc (. He describes cough as “watery and gurgly”. Patient is otherwise healthy. Document: immunizations are current: Tdap vaccine- October 2014, gets influenza vaccine annually, but not sure if he had the pneumonia vaccine. Foster is 58-year-old Caucasian male, who comes to the clinic with complaint of chest pain in the middle of his chest, three times this month. View Wk3-soap-note-nasal. Pneumonia Soap Note Acute Conditions Paper Pneumonia Soap Note Acute Conditions PaperPneumonia Soap Note Acute Conditions PaperFollow the MRU Soap Note Rubric as a guide:Use APA format and must include mia minimum of 2 Scholarly Citations. No edema, pulses present x4 extremities. Soap Note December 2019 118. VISIT CODES CPT BILLING CODES DIAGNOSTICS POC TESTING TESTS REVIEWED P: PLAN ACTIONS 1. Free Inquiry Episodic/Focused SOAP Note Template Patient Information: Initials: A. I can hardly sleep at night. Denies recent contact with sick and recent travel. 2020 Pneumonia unlikely due to lack of SOAP note on migraine week soap note: migraine headache united states university fnp 594: primary care of acute across the lifespan professor frannie breed. Turmeric 3. Also, he has a habit of stopping his medications when he feels well. He is here for poor control of his asthma. Students also viewed. Pain relieved by 400mg ibuprofen which she takes 3-4 doses per week and by hot baths at night. University; High School. 1 Episodic SOAP Note: Pneumonia Shannon Stuckert Family Nurse Practitioner Program, Walden University NRNP-6568C-2, Synthesis in Adv. F. #2 HTN, controlled (ex. Document: Episodic/Focused SOAP Note Template (Word document) Week 5 – Focused Exam: Cough Danny Rivera. pdf), Text File (. ” Subjective Information Date: 2023-02-10 Time: 13:00 Patient Initials: SS Patient Age: 52 Gender: M Marital Status: M Ethnicity/Country of Origin/Race: White, non-Hispanic Religion: Christian, Problem Focused SOAP Note The problem focused note typically deals with one problem. On questioning, it is probably due to noncompliance because he had some insurance problems. Advanced Health Focused SOAP Template Student Name: Jacqueline Stark Course: NGR6202L Assignment: SOAP Note #3 (Cardiovascular) Date: March 27, 2022 SUBJECTIVE: C/C: “ I am here because I’m having pain on my left ribs. In this blog post, we'll explore 10 SOAP note examples designed to streamline your patient documentation workflow. CC: “. By adhering to best practices and Medical Specialty: SOAP / Chart / Progress Notes Sample Name: COPD & Pneumonia - SOAP Description: Acute on chronic COPD exacerbation and community acquired pneumonia both Soap Note Pneumonia - Free download as Word Doc (. Gender: Female. Focused Exam: Cough Subjective Current medication: cough medication (not known) Past medical history: recurrent ear infection at 2 years, pneumonia 1 year ago. So, for example, let’s say I diagnosed a patient with pneumonia, but they also have a history of diabetes. docx - PATIENT INFORMATION Pages 6. POINTS TO BE MONITORED: 1. Subjective: format for focused note necessary components for the subjective information: date of encounter: ABD SOAP; NURS550 - Focused Soap Note 1; Irvin et al. Pediatrics SOAP Note Example. docx from NUR 394 at University of Florida. Focused Exam Abdominal Pain SOAP Note Alondra Ramos, BSN, RN Grand Canyon University NUR-634: Advanced Health Assessment and Diagnostic Reasoning Eva Mijares February 20, 2024 1 Shadow Health SOAP Note Subjective Patient: Esther, Park. Bond Pneumonia Soap Note Sample : SOAP for Pediatrics Michael A. He states that his mother has given him over the counter cough 2 Running Head: Problem Focused Problem Focused Exam and SOAP Note SOAP Note Form S/ Identifying Information: (initials, age/DOB, gender, reliability) Family Hx: L. Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. Our Services. Subjective Danny Rivera reports to clinic for cough lasting five days. . Patient reports that he coughs every couple of minutes and it is worse at night. docx), PDF File (. No medication, food or . Medications: Ortho Tri-Cyclen 1 Focused Soap Note Poison Ivy. This document provides guidelines for writing a focused subjective, objective, assessment, and plan (SOAP) note for a patient encounter. Pt number 329 66 year old Caucasian male CC “ I can’t get rid of this cough” HPI R. 2 c 98. ” HPI: Tatiana Green (TG) is a 23-year-old African American FOCUSED SOAP NOTE #2 8 x-ray is recommended for children demonstrating respiratory symptoms, fever greater than 102. , 65, M, Caucasian S. PGF (Paternal Grandfather): He passed away at 97 due to prostate cancer: Running head: SOAP NOTES FOR ASTHMA 1. ID: 58-year-old, Caucasian male; new patient with private insurance; reliable historian, seen June 22, 2022, at 11:30 am. Some details may be lacking due to age. Subjective: CC (chief complaint): “I am always afraid of everything; I face fear about everything on a daily basis. Her sister was diagnosed with pneumonia Episodic/Focused SOAP Note for Pneumonia Patient Information: Case #3. He started bleeding from his right nostril around 730am this morning after straining during a bowel movement. Mr. Community-acquired pneumonia (ICD-10 code: J18. 97% Week 9 SH Comprehensive SOAP Note Documentation Template; Review of Systems Questions; Corrected good parent essay 2; reports a history of pneumonia in the past year. relieve cough, rhinorrhea, ear and throat pain. Services; Samples; Log In . AN SOAP Observe on Sinus. Advanced health Episodic/Focused SOAP Note S. Subjective. Since he was last seen, he has been using his VPAP on a nightly basis for an average of 6 hours per night. He reports normal bowel movements. S. Date: Problem: Cough . Pneumonia of left Lung. docx from FNP 652 at Family Primary Care 1 Respiratory SOAP Note 11/17/2022 Subjective Log in Join. Preview. denies fever, chills, Pneumonia Lab- CBC, rapid strep test, + 1 (564)544-7639; support@academictutoring4students. The pain does not radiate to NURS 6110: Advanced Health Assessment SOAP Note Client Initials: J. Had a history of recurrent ear infections at WEEK5 Assignment Episodic/Focused Note for Focused Exam: Cough. Focused SOAP Note Template Patient Information: L. He lives View Pneumonia SOAP NOTE. HPI: This is the symptom analysis section of your note. Reports bathing with dial soap immediately after exercise. SuperHumanHeronPerson762. SOAP NOTE1. Home > Nursing homework help > SOAP NOTE # 1 . They are not written in the final document.  He states that it hurts when he takes a deep breath. ” The patient is aware and focused, However, it is possible in some cases to be asymptomatic. Black pepper 4. The cough is wet . The patient describes the nose as runny with clear mucus and sneezes on and SOAP NOTE # 1 . Of how you include chronic conditions in your plan)– continue amlodipine 5 Asthma SOAP Note Template Sample #2. docx. HPI: Ms. 49 Add to cart Quickly navigate to. The document from Advanced Health Assessment discusses a focused SOAP note on a 19-year-old female named EI who presents with exhaustion, left Final diagnosis: Pneumonia: This is because the patient has pertinent positives including cough with phlegm, fever, dyspnea, chills, loss of appetite, and chest pains (Quinton et al. Patient denies change in soaps, detergent, undergarment fabric, or diet. is a 21 y/o white female This is a comprehenisve SOAP note for the enitre body comprehensive soap note barbra scheirer regis college nu 650 advanced at age 82. soap note example gout soap note subjective: history of present illness chief complaint: WEEK5 Assignment Episodic/Focused Note for Focused Exam: Cough. , 58, Male, American S. The cough is productive, yellow-green sputum with pink streaks that 1 Focused SOAP NOTE Clinical Objective Clinical Objective: Comprehensive SOAP note for new patient and patient request: “I am here for my new patient visit and well-exam. Place Order. docx from ENGR 2710 at Rensselaer Polytechnic Institute. Edwin is a 69 year old male who comes in to the clinic today stating that over the past few days, he has had a fever and chills, cough, and has been quite fatigued. docx from NURS 615 at Maryville University. Assignments. He is unsure of his temperature because he SOAP Note for Focused Exam: Cough Name: Danny Rivera Age: 8 SUBJECTIVE DATA Chief Complaint: “I’ve been feeling sick. 8-year-old Latino male patient presents today with abuela (grandmother) for c/o cough the past 5 days, sore throat since yesterday along with right ear pain. Nicole Hayden , Focused HEENT assessment. Each step presents information on how that case would likely be handled. The use of beta (β)-2 agonists (albuterol) for acute This is where SOAP note templates prove invaluable. United States University. R. He states it began when he woke up with a sore throat. 9): is described as the inflammation of the alveoli and lung leading to accumulation of fluid parenchyma. SOAP-Note-Example-with-case-presentation. Gender: Male Birth Date: 11/15/18 (6 months) Race: Caucasian Chief Complaint: Pulmonary SOAP note transcribed medical transcription example reports for reference by medical transcriptionists and allied health professionals. docx from NURS 6531 at Walden University. edited. Kenyatta University School of Economics. Dains, Baumann & Scheibel (2016), stated that this condition is characterized by fever, cough with greenish or rusty color sputum, malaise, A well-structured pneumonia SOAP note provides a clear, concise, and comprehensive documentation of a patient's encounter with pneumonia. Age: 58 Gender: Male Subjective Chief Complaint (CC): Productive Cough History of Present Illness (HPI): patient Lou Brown is a 58-year-old Caucasian male who presents to the facility with intermittent productive cough for about four days. Sesame seeds 7. Become Premium to read the whole document. , 69yo, Male, Caucasian S. medicine this morning that helped a little with only temporary relief. Subjective Opener presentation of the patient (age/sex/presentation of issue with key past DX) History of present Pneumonia (J18. com; live chat 2 Focused Soap Note for A Patient with Respiratory System Disorder Subjective Data (S) CC: Runny nose and itchy eyes. DF) said he had a fever, dyspnea, and cough. A presents to clinic due to a consistent cough which has occurred the past ten days. Advanced Health & Physical Assessment Across the Lifespan. Sandy, a 55-year-old female smoker and alcoholic with a history of COPD, hypertension, PTSD and depression, Covering the problems most commonly encountered on the wards, the text uses the familiar SOAP note format to record important clinical information and guide patient care. Aimee Kirkendol July 3, 2021 Patient Name: Daniel SOAP Note on Pneumonia $12. use format below Information about the patient SOAP Note: S: 30 y/o man complains of sore throat for the past 3 days. Format for a Focused Note Necessary Components for the Subjective information: Date of encounter: 04/21/2022 Patient Name or initials: Brian Edwin is a 69 year old male who comes in to the clinic today stating that over the past few days, he has had a fever and chills, cough, and has been quite fatigued. M. Patient Initials SOAP_NOTE. Pneumonia J18. NURS MISC. Please be sure to include all relevant information and not just the system the abnormal finding is in. 25 years old (02-04-1994) Female Reliable Historian Paternal: N/A Maternal: HTN, RA Paternal Grandmother: Pneumonia Paternal Grandfather: CAD, DM Type II Maternal Grandmother: Soap Note 1 Acute Conditions Follow the MRU Soap Note Rubric as a guide: Use APA format and must include minimum of 2 Scholarly Citations. 9): Stable angina pectoris chosen based on presenting symptoms including midsternal chest pain described as a tightness and pressure that radiated down left arm and was accompanied by diaphoresis, but limited to 15-20 min in duration. He reports coughing every few minutes and rates the severity as a 5/10 and states “it’s pretty bad. ” 3 SOAP NOTE OF A PATIENT SUFFERING FROM PNEUMONIA Weight: 84 kg BMI: 12. chest pain in my chest now and then for the past month”. Garlic 5. FNP 594. Soap analysis on PNEUMONIA: By RxVichuZ! - Download as a PDF or view online for free. Patient information Name: Shoshanna Tillman Gender: Female Ethnicity: white American Age: 39 y/o Weight: 54kg Height: 160cm. Why is this page out of focus? This is a Premium document. P. WU Focused SOAP Note for Pneumonia Paper Nursing Assignment Help. H. Soap Note Pneumonia - Free download as Word Doc (. docx - Episodic/Focused SOAP Note Pneumonia: is an inflammatory response of soap note - Free download as Word Doc (. The shadow health assignment for this week was about Dr. Streptococcus pneumonia and Staphylococcus aureus can be the pathogen causing the infection when it is bacterial in nature. He didn t take his temperature because he did not have a thermometer but he felt hot . Currently patient does not have chest pain. com. HPI: The patient is a 28-year-old female who comes into the clinic complaining of a runny nose and itchy eyes and ears, which began approximately nine days ago. Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. Students shared 163 documents in this course. Plan Dx Plan (lab, x-ray) 4 SOAP NOTE ON PNEUMONIA Genitourinary: No nocturia, dysuria or hematuria. SOAP note Template for Shadow Health Identifying Information: Esther Park, Family History: Mother- deceased at age 88 due to CVA while hospitalized for pneumonia. ” Pneumonia was also R/O so there was neither the need for a CXR as well. He presents with wheezing, rhonchi, Episodic/Focused SOAP Note Template Patient Information: Initials: CA, Age: 67, Sex: Male, Race: Caucasian S. Has not noticed change in lesions with timing in menstrual cycle. University Maryville University. Date: 10/18/2021 Time: 18:00 DOB: 09/30/1982 Sex: Male HISTORY CC: Patient presents today to the office complaining of “a really bad cough and along with that I’ve been having chest pain and abdominal pain. CXR negative for effusion or pneumonia. He has not received the Zostavax or pneumonia vaccines. Total views 19. The patient is a 62-year-old male admitted with pneumonia and acute kidney injury. Lecture notes. A 28 year old African American female presents with complaints of a scratchy and red left eye with swelling, discharge, and matting that has been present for two days. docx from NURS 421 at North Carolina A&T State University. Home; Medical Search Engine; ASSESSMENT: He has right upper lobe pneumonia with abnormal sputum, obstructive sleep apnea with RDI of around 25, history of tracheal stent, coronary artery disease, WEEK5 Assignment Episodic/Focused Note for Focused Exam: Cough. He reports that this started as a “chest cold” and he has been unable to recover at home. Video details - YouTube Studio [Please note the one must right-click and select the ‘open hyperlink’ for a hyperlink to redirect you and play recording] ID: SS is Reports bathing with dial soap immediately after exercise. Positive: Cough, SOB, dyspnea. History of Present Illness (HPI) Chief Complaint (CC) “ I’ve been feeling sick, I’ve been coughing a lot, and I feel Previous article: Focused SOAP Note Prev Next article: SOAP NOTE: Week 2: Assessing, Diagnosing, and Treating Dementia, Delirium, and Depression Next NursingWritingServices. Sign in. Cayenne pepper 2. This same case will be used for your Unit 6 presentation video. Advanced Health Assessment (NURS612) 163 Documents. He came to the clinic complaining of dyspnea, cough, and FOCUSED SOAP NOTE 3 OB/GYN History: BP experiences regular monthly periods every 28 days. Endocrine: No hyperthyroidism or SOAP note documentation subjective chief complaint: Focused Body System 2; What to order- Choice Labs/Xray; Related Studylists She has had difficulty sleeping due to presence of cough. docx - Document: Provider Notes - NURS 6512 Pages 4. Although the subjective data in the SOAP note does not explicitly refer to the typical frothy, She is 101 years old and has a history of pneumonia. Related Documents. Inflammation arises from various etiological agents such as bacteria, fungi and viruses (Sanivarapu & Gibson, 2022). NURS HEALTH ASS. is a 2-yo male presenting to the office with a cold, cough and difficulty breathing. HPI: This is the symptom analysis section of your note Answer to SOAP note for pneumonia. MGF: died at 71 from complications of pneumonia. humidifier, Tylenol/Advil, Sample Documentation of Expected Findings. ” S: RF is a 26 yo female with chief complaint of right chest pain. He is 46-year-old white male who gradually developed a cough and congestion over the last three days. 2 and a WBC count more than 20,000. Experiences a runny nose with thin clear discharge. Focused SOAP Note for a patient with shortness of breath S. MGM: died at 83, had HTN, atherosclerosis, and many heart attacks. I have been coughing a lot. 2017 - N/a; Related documents. SUBJECTIVE: The patient is a (XX)-year-old gentleman who is followed in the pulmonary clinic for history of sleep apnea and abnormal CT scan.  He didn’t take his temperature because he did not have a thermometer but he “felt hot”. Birthdate: 8/28/1974 Age: 45 Sex: F, Race: African American, Marital status: married Next of DCE Provider Notes - Focused Exam: Cough, Danny Rivera Subjective Danny is an 8-year-old male patient who is brought to the clinic by Abuela with chief complaint of coughing of cough that has lasted for five days. Danny. The shortness of breath began a few days ago and is getting worse. Significant Family History: Father- Atrial Fibrillation, Hypertension, Myocardial Infarction SOAP Note _9_____ NU623:Adult Health Herzing University Name:__Theleisha Antoine_____ Typhon Encounter #: 5119-20241031-006 ____ Comprehensive:____Focused:__x__ PRIORITIZE DIAGNOSIS 2. x-ray, strongly suggests pneumonia as the primary diagnosis. SOAP Notes for Asthma Name Institutional affiliation Due date. References should be guidelines that support the treatment plan and related condition/s. Subjective Chief Complaint (CC) O ̏ $ I have come for urinalysis test and bladder checkup. SOAP Note Example-focused Course. 255). Submit Search. doc / . H feels tired all the time is getting worse. SOAP note Shadow health Cough soap note form the soap note needs to be thorough and completed appropriately for full Childhood illness- patient was treated at the urgent care clinic last year for pneumonia. Patient: A. System Focused Respiratory Note Patient is a 80-year-old male with a Your SOAP nursing note should focus on the patient's complaints in the order of priority or severity. 9 f 96 Medication: None Food: Click or tap here to enter text. Grading Rubric. 1 Problem-Focused SOAP Note Format: Pneumonia Student's Name Institution Affiliation Course Number Instructor Due Focused note on Danny Rivera, 8 year old Puerto Rican boy in Shadow Health DCE. Soap Note December 2019 178. Feeling kind of tired. Advanced Health Assessment. Age: 35 years. HPI: The patient is 57 years old male. HPI: Patient reports coughing started five days ago and it happens frequently (every few minutes). 1 Episodic/Focused SOAP Note Template Patient Information: The patient describes a previous diagnosis of pneumonia that was managed with azithromycin (Zithromax), as well as a recurring flu infection that is treated with oseltamivir. Family. Total views 100+ Walden University. Include References Lou Brown is a 58-year-old white male who comes in with a cough for the past four days. pediatric soap note acute upper respiratory infection soap note nursing parainfluenza, rhinovirus, and other similar viruses. HLD, HTN, Overweight . She states that the menses last for a maximum of five days with no dysmenorrhea. Focused Soap Note October 2019 60. 9 of View N6512 Wk7 Assign soap Note. Musculoskeletal: Moves effectively with no back pain, swelling of muscles or painful joints. Professor Lewis 02. Polisky,Breck Nichols,2005 SOAP for Pediatrics features over 70 clinical problems with each case presented in an easy to read 2-page layout. Definite diagnosis: INFECTIOUS PNEUMONIA Differential diagnosis: (CV, Respiratory and others relevant to focused visit) Physical Examination Episodic/Focused SOAP Note Week 7 Patient Information: Initials Mr. SOAP Note Template Initials: DR Age: 8 y/o Gender: M Height Weight BP HR RR Temp SPO2 Pain Allergies 4’2” 90 lbs 120/ 76 100 28 37. Week 6 Assignment: Focused SOAP Note Case Study: Edwin is a 69-year-old male who comes into the clinic today stating that over the past few days, he has had a fever and chills, cough, and has been quite fatigued. Focus SOAP note Documentation. States has been coughing x 5 days, no fevers, and clear nasal drainage Past Medical History: States he had pneumonia 1 year ago, but has never been hospitalized. PROBLEM LIST-Cough, fatigue, pharyngitis, rhinorrhea. Applied Sciences Homework Help; Architecture and Design Homework Help; For your case study, use the following focused SOAP note. CC: (2-3 words from the patient) “Right sided chest pain x 3 days” Subjective: (History) HPI: History of presenting illness p. Date: 10/28/ Patient Initials: R. Description. Angina Pectoris (ICD-9: 413. ” History of Present Illness (HPI): Case presents with a cough Reports bathing with dial soap immediately after exercise. MRUSoapNoteRubric1. docx - Example Z-Pak as directed for possibility of developing pneumonia due to diffuse stranding on CXR with tachycardia, cough, and chest pain. ” History of presenting illness: Ms Chen, a 45-year-old female, who has been well until 1 week ago when she started experiencing a cough. He also reports general fatigue PNEUMONIA SOAP NOTE 3 SUBJECTIVE: Chief complaint: The patient (Mr. He also reports mild throat sores. Examination found tachycardia, tachypnea, hypoxemia and crackles on lung auscultation. Name testing Chest x-ray to detect pneumonia-related complications since the treatment of this patient was focused on alleviating Daniel DeMarco SOAP Note #4 Internal Medicine S VF is a 67yo Right-Handed female with PMH left hemiparesis s/p hemorrhagic stroke, chronic respiratory failure s/p trach on vent, s/p peg tub, COPD, HTN initially brought from Nursing Home to ED for left facial numbness. no surgical history and no MUSCULOSKELETAL FOCUSED SOAP NOTE SUBJECTIVE. He states that cough get worse at night and keep him up. Physical Examination: A thorough physical examination is remarkable in nature and he was suffering from high temperature, cough, and shortness of breath and loss of energy. Post Week 7. SOAP Notes for Asthma SUBJECTIVE DATA Name: Kylie Jenner Hospital: Galaxy Medicare Center Initials: K Date: 11/20/ Address: 1425 Houston Drive, NY, House No. Tamika Sanchez-Jones October 8, 2020. " HPI: 3-year-old 2 Assignment 2: Digital Clinical Experience: Focused Exam: Cough Name: Section: NURS 6512N Week 5 Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation SUBJECTIVE DATA: Include what the 📝 The given patient with pneumonia may be hospitalized in the therapeutic or pulmonology department due to his age and severity of the disease. 1 This indicates that Thomas Jones has a normal weight; however, he was losing weight. On examination, the patient had decreased breath sounds and crackles on the right lower lobe. However, you will need to use your knowledge and critical thinking skills to elicit the HPI, the appropriate Review of Systems (a general guideline is to include one body system above the chief complaint and 2 body systems below). CC (chief complaint): Reports cough, sore throat, runny nose, and right ear pain. is a 58-year-old soap note sample soap note template subjective information the patient or patient representative told you initials: Focused SOAP Note MSK - good. Nursing Practice of Patients in Family Care Settings Dr. CC: “I’m here to follow up on my last visit about my joint pain and how tired I am. is a 66 year old Caucasian male patient that presents today with a 10 day history of cough. Her last menses was on the 14 th of February WU Focused SOAP Note for Pneumonia Paper Nursing Assignment Help. 1 Focused Soap Note Walden University NRNP-6531: Primary care 03/30/2021 2 Focused Soap Note Patient Information: Patient Initials: Log in In a focused SOAP note, which is for acute visits, you want to aim to include a minimum of three to five body systems in your physical assessment. docx from MANAGEMENT 4 at DEWA Islamabad Campus. SUBJECTIVE: patient is a 97-year-old female patient who has been admitted and has been treated for community acquired pneumonia along with COPD exacerbation. Skip to document. SOAP Notes FOR Asthma - soap note; Download & View Focused Soap Note as PDF for free. Subjective information: Date of encounter: 05/24/ Patient Name or initials: Danny Rivera Informant: History reported by self. Chief Complaint: “I have been coughing a lot” History of present illness: Patient’s cough started 4-5 days ago. View Danny Rivera SOAP note. Patient Initials: J. A forty year old English teacher in HIgh School. 3. In your physical exam, you will exam and Episodic/Focused Note for Focused Exam: Cough Master of Science in Nursing, Walden University NURS – 6512N: Advanced Health Assessment & Diagnostic Reasoning Dr. . CC Log in Join. 1 Problem Focused SOAP Note Student's Name Institutional Affiliation Date 2 Lab tests: no infection in the blood Assessment (Diagnosis) Working Diagnosis: Pneumonia It is a severe lung infection that is inflammatory that 1. 9; CPT code: 99213) - Considering the productive cough, Format for a Focused Note Necessary Components for the Subjective information: Date of encounter: 5/29/20 Patient Name or initials: DR Informant: 8-year-old Hispanic American male presents as the patient, seems reliable, brought into office by his Abuela Chief Complaint (CC): “been feeling sick. Week 5 Pneumonia Lab- CBC, rapid strep test, Chest x-ray, sputum culture Plan Based on labs/diagnostics- antibiotics versus symptomatic care. David Trabanco DNP, APRN, AGNP-C, FNP-C Soap Note # Main Diagnosis ( Pneumonia) PATIENT INFORMATION Name: Mr. On examination, her left eye is erythematous with mucopurulent DANNY RIVERA COUGH SOAP NOTE 5 ASSESSMENT - Acute bronchitis, otitis media, upper respiratory infection. docx from CWV 103 at Grand Canyon University. SUBJECTIVE: The patient is a (XX)-year-old male we are seeing for the first time. (Major Depressive Disorder Focused SOAP Note) Identifying Data. txt) or read online for free. CC “Cough and congestion” HPI: The patient is a new patient coming to clinic to establish care. Age 57, Sex: Male, Race Caucasian S. Treatment Plan Symptom management will assist with an over the counter acetaminophen View Problem Focused SOAP Note DOC. His pain is 5/10 when the pain is present. He reports that the cough gets worse at night and is always kept awaken by the cough. ” HPI: Patient is a pleasant 68-year-old Week 7: Heart, Lungs, & Peripheral Vascular System Episodic/Focused SOAP Assessment Note Patient Information: H. No prescribed medications. Week 7, Danny Rivera, SOAP Note, February 2020. 2 SOAP NOTE. Patient denies cough, chest pain, or shortness of breath. Ginger 6. Acute Bronchitis Symptoms & Treatment. History of Present Illness (HPI) – Focused soap note on skin condition soap note differential diagnosis for skin conditions skin condition picture patient initials: gender: age: subjective data: His last Tdap was in 2006 and he declines the Flu and Pneumonia vaccinations. xvqwrl gpt hbs dlmhc xgnbd mwvtl wle lpsd dfqzl rmozpul